Calling as a resource for health and occupational wellbeing among the care sector workers in Finland

Abstract

BACKGROUND:

The salutogenic approach in workplace health promotion emphasizes resources to gain and maintain good health and wellbeing. One of these resources could be calling, but its relation to the salutogenic approach is unknown.

OBJECTIVE:

To explore the associations between salutogenic measures of health and occupational wellbeing and calling among workers from the care and educational sectors.

METHODS:

A cross-sectional survey was conducted in Autumn 2020 among Finnish public and private sector care workers. A total of 7925 workers responded. Descriptive analyses and analysis of variance were used for the data analysis.

RESULTS:

Salutogenic measures of health and occupational wellbeing correlated strongly mutually, and both correlated moderately with calling. Workers aged over 55 years, workers acting in the education sector, workers with superior positions and temporary workers had the highest scores on health, occupational wellbeing and calling. When comparing occupational wellbeing dimensions by profession, managers had the highest scores and nurses the lowest.

CONCLUSIONS:

This study provides knowledge of promotive factors and health and occupational wellbeing resources for workplace health promotion in the care sector. Perceived calling in work can be considered a salutogenic resource for overall health and wellbeing; however, these connections should be further studied.

Keywords

Education health care salutogenic approach social services work experience workplace health promotion

1 Introduction

The care sector is a large industry worldwide. For example, the most popular profession in the United States among women is that of a nurse [1]. In Finland, a practical nurse was the second and a nurse was the third most popular profession in the whole population [2]. Currently, the care sector is facing some serious challenges. Populations in Western countries are aging which means there is an increased need for care and workforce. At the same time, care workers are aging; for example, one out of six nurses will retire in ten years globally, further increasing the need for workers [3]. In Finland, the pace is even faster; a quarter of nurses and a third of practical nurses will retire over the next ten years [4]. Already, the care sector is seeing a serious shortage of workers, and it seems that it is losing its attractiveness among young people. The shortage results from declining resources and adverse physical and psychosocial working conditions [5]. This development is seen in the care sector in the form of increased burnout and intentions to leave the profession [6 –8]. Therefore, it is crucial to study how the health and occupational wellbeing of care workers could be promoted in workplaces. This study applies the salutogenic approach to define resource-based and positive overall wellbeing and asks if perceived calling in work fits this theoretical framework.

The concept of occupational wellbeing has different meanings, and it is examined using several background theories and models [9, 10]. The models have in common that they include work factors and workers’ characteristics and resources in their work wellbeing assessments [11 –14]. A common precondition in these models for work wellbeing is a balance, that promotes the wellbeing of the employee at work either by reducing stress and strain or by promoting employee empowerment. For instance, Karasek’s [11] Job Demand – Control model has been used with Finnish home care workers when assessing job satisfaction, perceived stress and quality of care [15]. The Job Demands – Resources model [16], in turn, has been applied for studies examining job resources for nurses’ occupational wellbeing, which is promoted, for example, by mindfulness [17], social support [18] or passion [19].

Also, occupational wellbeing models and workplace health promotion can be defined by a diversity of health and wellbeing approaches either on a positive, i.e., resource [20, 21] or illness [22] basis. A pathogenic perspective focuses on work-related risks of disease or morbidity and has long been dominant in workplace health research [23]. The complementary salutogenic approach focuses on work-related resources for health regardless of possible morbidity [24, 25]. Workplace health promotion that applies a salutogenic approach is ultimately about creating strengthening workplace conditions and experiences for employees to take control of their health and identify the work-related factors and processes that affect health [26, 27].

In workplace activities aiming to promote workers health, the use of different measurement tools is valuable to get a result depending on whether it is health or illness that is in focus [28]. Measurement tools to identify salutogenic work-related factors and processes are needed in workplace health promotion practice and research. Surveys that examine employees’ experiences of work and work situations from a salutogenic approach are few and were used, for example, in investigating hospital employees [29], workplace dental care [30] and workplace health interventions [31]. It is more common that pathogenic factors such as stress and risks of ergonomic injury are measured [32]. But in workplace health promotion, it is not enough only to identify the problems in the workplace; equally important is to identify positive factors that contribute to workers’ health [28, 33]. The specific work-related or individual resources can be different according to the workplace and which work tasks the employees are conducting [20, 34]. For instance, in the care sector with human care professions, a possible health resource that is less talked about is calling.

Care professions are traditionally considered as careers of calling. In the care sector, calling is an essential factor guiding career choices and helping to stay in a profession [35]. Calling in care work and notably in nursing has its origins in Florence Nightingale’s times [36]. An altruistic and intuitive inner compulsion to serve other people has been seen mainly as a feminine trait [37, 38]. Research on calling divides it into classical, modern and neoclassical orientations [39 –41]. The classical orientation has religious roots referring to people’s professional destiny and duty [41]. The modern calling seeks a meaningful career that provides fulfilment in life [40]. The neoclassical orientation understands calling as a three-dimensional construct [39, 41]. The first dimension of neoclassical orientation refers to the classical definition, and the second dimension refers to modern orientation. The third dimension refers to classical orientation, stating that meaningfulness is derived from serving the common good of society. These three dimensions are labeled as Transcendent summons, Purposeful work, and Prosocial orientation [39].

Calling has been associated with several positive work-related outcomes among care workers by increasing work motivation [42], job satisfaction [43], work engagement [44] and coping with job demands [42]. Caring-specific aspects are shown as nurses’ compassion [35, 45], patients’ experiences of good care [46] and quality of care and safety [47]. A link to the salutogenic approach is through the sense of coherence since Colomer-Pérez et al. [48] found that calling advanced nursing students’ performance and sense of coherence. Sense of coherence is a core concept of the salutogenic health approach, referring to an ability to conceive life as comprehensible, manageable and meaningful [49]. This study aimed to explore the associations between salutogenic measures of health and occupational wellbeing and calling among care and education sector workers.

2 Methods

2.1 Study context

Finland is undergoing a major social and health care reform, where the responsibility for organizing services is transferred from over 300 municipalities to 22 larger regions [50]. However, education and early education will continue to be the responsibility of municipalities, as will the promotion of the health and wellbeing of the residents. Health and social services are mainly funded by taxes and offered by public providers. The share of the private sector is currently 25%, but the private sector has grown strongly recently [51]. For example, a third of the personnel in social services worked for private providers in 2014 [52]. However, the role of the private sector in the reform is not clear, but the overall aim has been to highlight the role of the public sector as a coordinator for organizing the various services.

2.2 Data collection and participants

Data for this study were collected by an online questionnaire from care and education sector workers in Autumn 2020 in Finland. Care workers were recruited via three trade unions and one workforce leasing company (N = 93 000). Trade unions represented public and private sector care workers in health care, social services, early education, childcare and school assistance, but not schoolteachers. Contact persons sent the invitations to the two trade unions and workforce leasing company members, and one trade union informed the study in their monthly newsletter.

Of the 7925 respondents response rate: 8.5% seven did not give their informed consent, and their data were removed. Also, data from the unemployed (n = 101), retired persons (n = 60), full-time students (n = 155), and those who were absent from work because of parental leave (n = 129) or disability (n = 178) were removed. The final sample included 7256 care workers from different working sectors, such as nurses (n = 373), practical nurses (n = 5004), social workers such as counsellors and assistants (n = 1405) and early education teachers (n = 123). The respondents were of various ages, genders, and levels of education.

2.3 Study variables

Health was assessed with the Salutogenic Health Indicator Scale (SHIS), which measured individual experiences of physical, mental and social wellbeing [53]. The scale has an overall question: How have you felt in the last 4 weeks with regard to the following? This question is followed by 12 statements as a semantic differential, options ranging from positive (6) to negative (1). An example of a statement is: In the last 4 weeks, I have felt ... alert (6) ... felt tired, exhausted (1). SHIS was used as one index for health, giving a total sum from 12 to 72. The sum was standardized to correspond to a scale of 0 to 100, and a higher score indicated better health.

Occupational wellbeing was measured with the Work Experience Measurement Scale (WEMS) [28] which assesses experiences of work and work situations. The scale has six subscales: Supportive working conditions (seven statements), Internal work experiences (six statements), Autonomy (four statements), Time experience (three statements), Leadership (six statements), and Process of change (six statements). Each statement was answered with the six-point Likert scale, with options ranging from Totally agree (6) to Totally disagree (1). An example of a statement is: We encourage and support each other at work. First, a sum of each subscale was calculated, and then subscales were standardized to a scale ranging from 0 to 100 because there were a different number of statements per subscale. A total score was a mean of subscales, higher score indicating better occupational wellbeing.

Calling was measured with the Calling and Vocation Questionnaire (CVQ) [54]. The CVQ includes two dimensions of calling: CVQ Search, which evaluates a search of one’s calling, and CVQ Presence, which assesses a current calling. This study used the CVQ Presence subscale with 12 statements. CVQ Presence can be further divided into three dimensions: Transcendent summons, Purposeful work, and Prosocial orientation, each with four items. Response options for statements ranged from (1) Not at all true of me to (4) Absolutely true of me. An example of the statements is as follows: I believe that I have been called to my current line of work. A total score was the mean of all items, and a higher score indicated a higher level of calling.

All the measurement instruments applied in this study, SHIS, WEMS and CVQ, were double translated by an authorized translator, discussed in a research group and tested before the data collection. Background data such as age divided into three groups, gender, level of education, working sector, current profession and type of employment contract was also collected based on self-report. The highest gained education was classified as a professional degree, which is typically a three-year education, and a university degree, including a Bachelor’s or a Master’s degree. The working sector was divided into three groups. Health care included hospitals, public health centers and private clinics. Social services included, for instance, nursing homes and other care services for the elderly, disability services and additional social assistance. The education sector contained early education and care, school assistance, and afternoon care and youth clubs. Type of employment contract was either permanent or temporary which combined temporary and temporary agency workers.

2.4 Data analysis

To examine possible non-response bias due to low response rate, we compared 100 first and 100 last respondents because the last ones probably resembled those not responding [55]. We did not find significant differences in age, gender or education between the two groups. The levels of missing values per variable were low, ranging from 0,7% to 2,2%, so we did not replace any missing values. The internal consistency of each scale was assessed as a Cronbach’s alpha coefficient. We used descriptive statistics to present sample characteristics and t-tests and analysis of variance (ANOVA) to test differences between groups. Correlations were analyzed with Pearson’s correlation coefficient and were considered moderate when r≥0.30 and strong when r≥0.50. P-level was significant when≤0.05. SPSS version 27 was used for the analyses.

2.5 Ethical considerations

According to Finnish legislation, this type of study does not need ethical approval from an official ethics committee. However, the Institutional Review Boards of the participating trade unions granted permissions for data collection. Members of trade unions and a workforce leading company received the information letter and the description of data protection procedures applied in the study. Participation was voluntary, and participants were asked to give their informed consent before completing the questionnaire.

3 Results

The average age of the respondents was 48 years; about half were between 35 and 55 years old and one third were over 55 years old. Most of the respondents were women (94%), and the largest sector represented was health care (38%), followed by the social sector (35%). Practical nurses were the most significant professional group (70%), and correspondingly, professional degree (79%) was the most often gained highest level of education. Most of the respondents (84%) had a permanent employment contract. See Table 1 for more details.

Table 1
Background characteristics of care workers (n = 7256)

Mean (Sd) n %

Age, years 48,4 (10,6)

<35 904 12,7

35–55 3972 55,8

>55 2238 31,5

Gender

Male 429 6,0

Female 6736 94,0

Education

Professional degree 5722 79,1

University degree 1513 20,9

Sector

Health care 2719 37,8

Social services 2548 35,4

Education 1932 26,8

Profession

Practical nurse 5004 70,0

Registered nurse 373 5,2

Social worker 1405 19,6

Early education teacher 123 1,7

Manager 74 1,0

Other^a 173 2,4

Employment type

Permanent 6051 84,0

Temporary 1156 16,0

	Mean (Sd)	n	%
Age, years	48,4 (10,6)
<35		904	12,7
35–55		3972	55,8
>55		2238	31,5
Gender
Male		429	6,0
Female		6736	94,0
Education
Professional degree		5722	79,1
University degree		1513	20,9
Sector
Health care		2719	37,8
Social services		2548	35,4
Education		1932	26,8
Profession
Practical nurse		5004	70,0
Registered nurse		373	5,2
Social worker		1405	19,6
Early education teacher		123	1,7
Manager		74	1,0
Other^a		173	2,4
Employment type
Permanent		6051	84,0
Temporary		1156	16,0

^ae.g., Cleaners, secretaries.

Table 2 shows means (SD) for health (SHIS), work experience (WEMS) and calling (CVQ) by background characteristics. Workers over 55 years old had significantly higher scores in SHIS than those under 35 years old. Health care workers had the lowest scores in SHIS, and workers in the education sector had the highest scores. Also, nurses and practical nurses had lower scores in SHIS than all the other care professionals. Employment type was also significant concerning SHIS; temporary workers had higher scores than permanent workers. WEMS scores were significantly higher among older workers, men and workers in the education sector than among younger workers, women and health care workers. Furthermore, nurses had the lowest scores in WEMS and managers the highest. Temporary workers also had higher scores in WEMS than permanent workers. Calling (CVQ) was higher among older workers and women compared to younger workers and men. Workers in health care and nurses perceived the lowest levels of calling compared to the other sectors and professional groups. Finally, permanent care workers had lower scores in CVQ compared to temporary workers. Education was the only background variable that showed no difference between the educational groups in SHIS, WEMS and CVQ.

Table 2

Means (Sd) for health (SHIS), work experience (WEMS) and calling (CVQ) compared by background variables

	SHIS^a		WEMS^b		CVQ^c
	Mean (Sd)	p	Mean (Sd)	p	Mean (Sd)	p
Age, years		<0.001		<0.001		<0.001
<35	52,45 (20,39)		52,15 (16,98)		2,59 (0,58)
35–55	57,41 (20,22)		54,66 (16,78)		2,64 (0,57)
>55	58,86 (20,73)		56,28 (16,91)		2,70 (0,56)
Gender		0.934		0.007		0.001
Male	57,11 (21,68)		56,93 (17,53)		2,56 (0,60)
Female	57,20 (20,40)		54,66 (16,84)		2,65 (0,57)
Education		0.067		0.488		0.220
Professional degree	56,93 (20,49)		54,69 (16,86)		2,65 (0,57)
University degree	58,02 (20,38)		55,03 (17,05)		2,63 (0,57)
Sector		<0.001		<0.001		<0.001
Health care	53,94 (20,85)		51,86 (16,929)		2,59 (0,58)
Social services	56,85 (20,16)		55,41 (17,00)		2,65 (0,57)
Education	62,00 (19,36)		57,88 (15,98)		2,72 (0,54)
Profession		<0.001		<0.001		<0.001
Practical nurse	56,04 (20,57)		53,53 (16,71)		2,63 (0,57)
Registered nurse	55,67 (19,16)		51,00 (16,67)		2,54 (0,57)
Social worker	60,90 (19,76)		59,40 (16,20)		2,72 (0,54)
Early education teacher	60,62 (20,17)		56,31 (16,50)		2,70 (0,55)
Manager	63,73 (18,26)		61,50 (17,40)		2,76 (0,57)
Other	58,16 (21,51)		59,97 (18,02)		2,63 (0,64)
Employment type		0.005		<0.001		0.010
Permanent	56,83 (20,50)		54,42 (16,80)		2,64 (0,56)
Temporary	58,71 (20,27)		56,31 (17,24)		2,69 (0,59)

^aSalutogenic Health Indicator Scale. ^bWork Experience Measurement Scale. ^cCalling and Vocation Questionnaire.

The WEMS subscale scores by occupations are presented in Table 3. Overall, the highest scores among all the occupations were seen in the dimension of Internal work experiences, and the lowest scores were in the dimension of Process of change. Of all the professionals, nurses had the lowest scores in every dimension except for Internal work experiences and Time experience, where their scores were the second lowest. Managers had the highest scores in all the dimensions except for the Time experience, which was the highest in other professionals. The differences between occupations were significant (p < 0.001).

Table 3

Correlations between health (SHIS), calling (CVQ), work experience (WEMS) and six dimensions of WEMS

	SHIS^a	CVQ^b	WEMS^c	Supportive working conditions	Internal work experiences	Autonomy	Time pressure	Leadership	Process of change
SHIS	α = 0.94
CVQ	0,336*	α = 0.86
WEMS	0,649*	0,446*	α = 0.94
Supportive working conditions	0,613*	0,407*	0,823*	α = 0.62
Internal work experiences	0,559*	0,649*	0,707*	0,667*	α = 0.84
Autonomy	0,453*	0,337*	0,725*	0,515*	0,485*	α = 0.85
Time pressure	0,442*	0,168*	0,700*	0,460*	0,304*	0,440*	α = 0.78
Leadership	0,465*	0,276*	0,813*	0,680*	0,470*	0,424*	0,450*	α = 0.91
Process of change	0,477*	0,294*	0,783*	0,579*	0,446*	0,416*	0,410*	0,648*	α = 0.93

*p < 0.01. ^aSalutogenic Health Indicator Scale. ^bCalling and Vocation Questionnaire. ^cWork Experience Measurement Scale.

The internal consistencies of all the study scales were good (Table 4). The correlations between SHIS, CVQ, WEMS, and WEMS subscales were significant at p < 0.01. SHIS correlated strongly with the total WEMS scale (r = 0,649) and the subscales Supportive working conditions (r = 0,613) and Internal work experiences (r = 0,559). CVQ correlated moderately with SHIS (r = 0,336) and WEMS (r = 0,446), and strongly with the WEMS subscale Internal work experiences (r = 0,649). All the other correlations were moderate, except for the correlations between the CVQ and WEMS subscales Time experience, Leadership and Process of change, which were weak.

Table 4

Means (Sd) for WEMS subscales among registered nurses (n = 373)

	Mean (Sd)
Supportive working conditions	54,56 (0,76)
Internal work experiences	70,90 (1,02)
Autonomy	45,78 (1,27)
Time pressure	47,87 (1,34)
Leadership	50,24 (1,36)
Process of change	36,23 (1,25)

4 Discussion

This study explored health, occupational wellbeing and calling among different care workers and provided a comprehensive assessment of these intertwined aspects in current working life. Given that the applied salutogenic approach emphasizes positive outcomes and resources, we correspondingly discuss our findings. However, the findings also shed light on the care sector’s problematic timely issues, notably those in nursing.

First, we compared SHIS, WEMS and CVQ by background factors and found interestingly that older workers had higher scores in every measurement scale. It seems that the salutogenic health instrument applied in this study can detect positive health because when health is assessed with other instruments, such as one question about self-rated health (SRH), the older workers tend to have lower scores. The salutogenic approach for health and occupational wellbeing might thus produce an assessment of wellbeing close to the quality of life and positive life situations, which strengthen by age [56]. The other salutogenic construct used to explain health, namely the sense of coherence, is also higher among older people [57]. Sense of coherence bridges the notions of salutogenic health and occupational wellbeing with calling by the experience of meaningfulness. In our study, the meaningfulness that work brings to life results in better overall wellbeing.

We also found gender differences in WEMS and CVQ; men had better occupational wellbeing, and women perceived higher levels of calling. Given that calling is gender-specific, women perceive higher levels of calling in the sector considered feminine [58] with a presumption that they have an altruistic desire to engage in caring [37]. Interestingly, SHIS, WEMS and CVQ were higher among workers in the education sector, and health care scored the lowest. This finding somewhat corresponds to the differences between professions, as nurses and assistant nurses had the lowest scores on every scale. Earlier studies applying the salutogenic approach to health and occupational wellbeing found similar patterns among health care professionals [29]. Our data was collected during the COVID-19 pandemic and comparing our findings (SHIS mean score 55,7; WEMS mean score 51,0) with earlier results (SHIS 68,5; WEMS 66,2) [29] shows that COVID-19 has probably decreased health and occupational wellbeing in health care. On the other hand, managers had the highest scores in SHIS, WEMS and CVQ, which corresponds with the previous findings [28]. In the care sector, managers might have more resources that support health and occupational wellbeing and help them maintain calling. These resources could include, for example, autonomy, more rewarding and challenging work tasks, better work-life balance due to a daytime job, and better pay [59].

We explored scores for WEMS subscales, and all the professional groups had the highest scores for Internal work experiences while Process of change had the lowest scores. These dimensions have been previously shown as the highest and the lowest among Swedish nurses [28] and among Lithuanian nurses, except that Internal work experiences was the second highest among Lithuanian nurses [29]. Predictably, managers had the highest scores in every dimension except for Time experience, which was highest among other care workers, such as cleaners and secretaries. This group of workers in the care sector had, on the contrary, the lowest scores in Internal work experience, which suggests lower perceived meaningfulness from work. However, these workers did not have the lowest scores in calling, but the nurses perceived less calling in their work than care sector cleaners and secretaries. Furthermore, nurses had the lowest WEMS subscale scores in Supportive working conditions, Autonomy, Leadership and Process of change. These results probably reflect the overall developments in nursing with its shortage of workers, increasing workloads and decreased attractiveness [60]. For example, nurses may tend to deny the presence of calling because it has been used as an excuse for a poor salary [61].

Interestingly, temporary workers experienced better health, had better occupational wellbeing and perceived higher levels of calling. Earlier findings on the effects of temporary work on wellbeing are contradictory; a large number of studies have shown the negative health effects of job insecurity [5, 62]; however, contrary findings have shown that temporary health care workers had better wellbeing compared to permanent workers [63]. Temporary employment, if conceptualized as insecurity, indeed specifically affects mental health [62], but temporary work may also be voluntarily chosen which is the most probable explanation in our results. In times of staff shortages, care workers’ employability is very good. When one employment contract ends, another is found immediately; the actual fear of unemployment is non-existent. It is plausible that temporary care workers have more control and autonomy over their working times, workplaces, and leave, and they may gain a better work-family balance. They also might have fewer responsibilities in the working community, and they do not have to take on additional tasks [64].

The correlations among the SHIS, CVQ, WEMS, and WEMS subscales were significant. This is interesting from a salutogenic point of view, as it shows that health, calling, and work experience relate and influence each other. The earlier results from calling studies confirm the positive associations of calling with occupational wellbeing components such as work motivation and work engagement among nurses [42, 44]. It is valuable information in practical workplace health promotion activities that an activity aiming to strengthen worker’s health, calling or occupational wellbeing will also have the possibility to enhance one another as they seem to influence each other. This is confirmed from previous studies showing that SHIS and WEMS mutually reinforce each other [28, 29]. For instance, these survey instruments could be used in workplace health promotion as a dialogue material for group discussions to understand calling as a work resource that may strengthen the ability to see connections to and enhance health and occupational wellbeing.

4.1 Strengths and limitations

The strength of this study was the innovative exploration of the concept of calling as a salutogenic resource for health and occupational wellbeing. The large and nationally representative sample of care workers can also be considered a strength of this study. However, the total response rate was only 8,5% which can be regarded as low, but the response rates for these types of untargeted surveys tend to be as low as 10%. To address the possible bias due to non-response, we compared the first and last respondents [55]. We did not find any differences in the background factors of these two groups, which reduced the risk of bias. The total number of respondents was 7256, which should still be considered a sufficiently large number to show a credible picture of the target group’s answers. However, the generalizability of the study is low because of the heterogeneity of the professions in the study sample. Another issue to remember is the COVID-19 pandemic which may have affected the results. The probable influence of the pandemic was that it decreased the health, occupational wellbeing and calling among care sector workers by increasing the psychological and physical burdens of work. Therefore, studying salutogenic wellbeing factors and calling in the post-pandemic era is essential. Also, after the actual threat of the pandemic has passed, we will be able to see its total effects on the care sector workforce.

5 Conclusions

Perceived calling in work can be considered a salutogenic resource for overall health and wellbeing. The salutogenic approach on health and occupational wellbeing fitted well with the Finnish context among care sector workers, as the results are parallel with the previous studies. Remarkable differences in health, occupational wellbeing and calling exist between care sector professionals, and notably, nurses’ working conditions and working life quality should be improved as a matter of urgency. Workplace health promotion measures emphasizing positive aspects and resources in work are also crucial for the care sector’s future and attractiveness.

Ethical approval

According to Finnish legislation, this type of study does not need ethical approval from an official ethics committee.

Informed consent

Participation was voluntary and participants were asked to give their informed consent before completing the questionnaire.

Conflict of interest

The authors declare that they have no conflicts of interest.

Footnotes

Acknowledgments

Not applicable.

Funding

This work was funded by the Finnish Work Environment Fund (200197). The funder had no role in the study design, data analysis, decision to publish, or preparation of the manuscript.

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